Initial Client Intake Form

Please take your time to carefully fill out this form with as much detail as possible related to your overall health. 

Contact Information
Full Name *
Full Name
Medical History
In order to help us meet your needs as a patient, we ask that you provide us with the following information. It is important that all information is reported accurately. If at any time there are changes in your condition, please notify your provider.
Please list all medications, supplements and herbs, including frequency of use and dosage.
Marital Status
What is your current occupation?
Please list your top three health concerns that you would like to address with Pure Balance.
Please list all known medication, food and environmental allergies.
Please describe in as much detail as possible your family medical history, including parents, siblings, grandparents and children.
Please list all hospitalizations, surgeries, procedures, transplants and injuries, including dates.
Current Conditions
Please check all conditions that you present with.
General Symptom Profile
Please check all that you have experienced within the past year.
Cardiovascular Symptom Profile
Please check all that you have experienced within the past year.
Respiratory Symptom Profile
Please check all that you have experienced in the past year.
Gastrointestinal Symptom Profile
Please check all that you have experienced within the past year.
Genitourinary Symptom Profile
Please check all that you have experienced in the past year.
Neuropsychological Symptom Profile
Please check all that you have experienced in the past year.
Musculoskeletal Symptom Profile
Please check all that you have experienced in the past year.
Please feel free to use this space to elaborate on symptoms or to add any additional symptoms that you may have experienced in the past year or may be currently experiencing.
Do you have any concerns related to menstruation, peri-menopause or menopause? Please describe the regularity of your cycle. Have you ever had an abnormal mammogram/thermography scan? Have you ever had abnormal lab findings? Have you had a hysterectomy or partial hysterectomy? Do you have a history of endometriosis?
Please tell us if you have any men's health concerns. Have you had a recent prostate exam, PSA test or colonoscopy? Do you have sexual dysfunction or impotence? Have you had a vasectomy?
Nutritional Intake
Please check all that apply.
Please use this space to express any concerns about nutrition you may have.
Do you consume alcohol? If yes, what? How much? And for how many years?
Do you smoke? What? And How much? Have you tried to quit? How many times?
How frequently do you have bowel movements? What is the typical color and consistency?
Please describe your current level of physical activity.
On a scale of 0-10 (0 being no stress and 10 being maximally stressed) please rate your emotional stress level.
Please describe your sleep patterns and average sleep per night. Do you wake feeling refreshed?
Please describe your 3 greatest physical health assets and 3 greatest areas of need.
Please describe your 3 greatest intellectual health assets and 3 greatest areas of need.
Please describe your 3 greatest emotional health assets and 3 greatest areas of need.
Please describe your 3 greatest spiritual health assets and 3 greatest areas of need.
Payment Information
We accept cash, check, and credit card payments. Please make checks payable to: Pure Balance Holistic Healing. Payment is due at time of service. **Session rates are $120 for 60 minutes and $170 for 90 minutes. Holiday, Saturday and Sunday $150/$200. Outcalls begin at $225. CANCELLATION POLICY: Your appointment time has been reserved exclusively for you; any change in appointments greatly impacts availability for other clients. • In event of an appointment cancelled within less than 24 hours notice, you will be charged 50% of the cost of the missed appointment. • In the event you do not attend your session and do not notify our office, you will be charged for your full session. FINANCIAL POLICY: In the event of a returned check, the fee assessed by your bank will be billed to your account.
Please initial in agreement with the Payment Information.
Informed Consent
I hereby request and consent to the performance of physical therapy services and other types of physical evaluations, procedures and treatments, including various modes of physical therapy, on me (or on the patient named below, for whom I am legally responsible) by the physical therapist named below and/or other licensed physical therapists who now or in the future work at Pure Balance Holistic Healing, LLC. I have had an opportunity to discuss with my treating physician and the physical therapist named below and/or with other office or clinic personnel the nature and purpose of my physical therapy and other procedures. I understand that results are not guaranteed. I further understand and have been informed that physical responses to a specific treatment can vary widely from person to person and it is not always possible to accurately predict my response to certain physical therapy modalities or procedures. I also understand that the physical therapist named below is not able to predict precisely what my reaction to a particular treatment might be, or guarantee that my treatment will help or cure the condition I am seeking treatment for. I also understand that there are some risks that my treatment may cause pain or injury, or may aggravate a previously existing condition. I do not expect the physical therapist to be able to anticipate and explain all the risks and complications, and I wish to rely upon the physical therapist to exercise judgment during the course of my treatment which the physical therapist feels at the time, based upon the facts then known to him or her, is in my best interest. I have the right to ask my physical therapist what type of treatment he or she is planning based on my history, diagnosis, symptoms and testing results. I have had the opportunity to discuss with my physical therapist what the potential risks and benefits of a specific treatment might be. I have also been informed that I have the right to decline any portion of my treatment at any time before or during my treatment session. I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content and all of my questions have been answered to my satisfaction. I understand the risks associated with the program of physical therapy discussed with me and I wish to proceed. By signing below, I agree to the above-named physical therapy services. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.
Please initial in agreement with the Informed Consent
Acknowledgement of Patient Bill of Rights and Notice of Privacy Practices
PURE BALANCE HOLISTIC HEALING, LLC’S NOTICE OF PRIVACY PRACTICES 6 October 2016 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY I. UNDERSTANDING YOUR HEALTH RECORDS/INFORMATION: Each time you visit Pure Balance Holistic Healing, LLC (hereinafter “Pure Balance”), a record of your visit is made. Typically, this record contains your symptoms, examination, test results, diagnoses, treatment, and a plan for future care. This information, often referred to as your health record or health information, serves as a: * • Plan for your care and treatment. * • Communication source between health care professionals. * • Tools with which we can check result and continually work to improve the care we provide. * • Means by which Medicare, Medicaid or private insurance payers can verify the services billed. Understanding what is in your health record and how the information is used helps you to: * • Ensure its accuracy. * • Better understand why others may review your health information. * • Make an informed decision when authorizing disclosures. II. PURE BALANCE’S RESPONSIBILITY Pure Balance is required by law to: * • Maintain the privacy of your health information. * • Inform you about our privacy practices regarding health information we collect and maintain about you (hereinafter “Privacy Practices”). * • Honor terms of this Notice. Pure Balance will keep your oral, written, and electronic health information safe using physical, electronic, and procedural means. These safeguards follow federal and state law. Pure Balance reserves the right to change its Privacy Practices and to make the new provisions effective for all health information it maintains. We may tell you about any changes to our Notice in a number of ways. We may tell you about the changes in a newsletter or post them on our website. We may also mail you a letter that tells you about any changes. Pure Balance will also post any revised Notice of Privacy Practices at public places in its physical facility. Note: The federal privacy law (the Health Insurance Portability and Accountability Act of 1996, hereinafter “HIPPA”) generally does not preempt, or override other laws that give people greater privacy protections. As a result, if any state or federal privacy law required us to provide you with more privacy protections, then we must also follow that law in addition to HIPPA. Pure Balance will not use or disclose your health information without your permission, except as described in this Notice and as permitted by the HIPPA Privacy Regulations. III. HOW PURE BALANCE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU The following categories describe how we may use and disclose health information about you. * • We will use and disclose your health information to provide your treatment. For example, we may disclose your personal health information to primary care providers or other medical care providers who request it to aid in your treatment. If Pure Balance consults with a health care facility, Pure Balance will exchange your health information with that health care facility for treatment decisions. * • We will use your health information for health care operations. For example, we may use your health information to evaluate your care and outcomes. This information will be used to continually improve the quality and effectiveness of the services we provide. IV. PURE BALANCE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU WITHOUT YOUR CONSENT OR AUTHORIZATION FOR THE FOLLOWING PURPOSES: Required by Law: We may use or disclose your personal health information, as we are required to do by federal, state, or local law. As required by law, we will disclose your health information to public health, or health oversight authorities or legal authorities charged with preventing or controlling disease, injury, or disability. We will also disclose your health information to legal authorities charged with receiving reports of child abuse or neglect or domestic violence. We may disclose your health information to an individual who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition. We may disclose your health information to the extent necessary to avoid a serious and imminent threat to your health or safety or to the health and safety of others. We may also have to report certain work-related instances and injuries to your employer so your work place can monitored for safety. We may disclosure your health information in response to a court order or upon the request from your military command authorities, if applicable, or for any workers’ compensation or similar program as required by law. It will not be a violation of this Notice if we, or any of our employees, business associated or contractors discloses information pursuant to whistleblowers and disclosures by workforce member crime victims Communication with your designee: If you have directed that your health information may be disclosed to a family member, relative, friend or any other person you identify. This disclosure of health information is relevant to that person’s involvement in providing care or payment for services. Appointment Reminders: We may contact you to remind you about an appointment for services. Note: Except for the situations listed above, we must obtain your specific written authorization for any other release of your health information. An authorization is different that consent. One primary difference is that unlike with consents, a provider must treat you even if you do not wish to sign an authorization. If you sign an authorization, you may withdraw your authorization at any time, as long as your withdrawal is in writing. If you wish to withdraw your authorization, please submit your written withdrawal to Pure Balance directly. V. YOUR RIGHTS TO YOUR HEALTH INFORMATION Although your health record is the physical property of Pure Balance, the information belongs to you. All requests in connection with the following rights must be in writing. You have a right to: * • Inspect and copy your health information. With a few exceptions, you have the right to inspect and obtain a copy of your health information. Pure Balance may charge a copying fee of 10 cents per page after the first 10 pages. * • Request a restriction on certain uses and disclosures of your health information. Pure Balance is not required to agree to any requested restriction. * • Request an amendment to your health records if you believe your health information is incorrect or incomplete. * • Request confidential communications about your health information. You may request confidential communications by an alternative means and Pure Balance will accommodate all reasonable requests. * • Request an accounting of disclosure of your health information. You have a right to ask for an accounting of disclosures of your health information we have made up to six (6) years prior to when the request is made. The accounting of disclosures must include the date of each disclosure, who received the disclosed health information, a brief description of the health information disclosed, and why the disclosure was made. Pure Balance my not charge you for the list, unless you request such a list more than once per year. In addition, we will not include in the list disclosures made to you, or for purposes of treatment, payment, health care operations, national security, law enforcement/corrections, and certain health oversight activities. * • Request a new copy of this Notice at any time. Even if you have agreed to get this Notice by electronic means, you still have the right to a paper copy upon request. VI To exercise your rights under this Notice, to ask for more information, or to report a problem, you may contact the Privacy Official below: Krystal Couture Pure Balance Holistic Healing, LLC 875 Islington St Portsmouth, NH 03801 Telephone (603) 387-3347 If you believe your privacy rights have been violated, you may file a written Complaint with the above individual or the Office of Civil Rights in the U.S. Department of Health and Human Services, Washington, DC . There will be no retaliation for filing a Complaint. You may file a Complaint at either entity. I have read and understand the Patient Bill of Rights and Notice of Privacy Practices for Protected Health Information, which provides a detailed description of the potential uses and disclosures of my protected health information and my rights as a patient. I understand that I may request a hard copy of this form at anytime during my treatment at Pure Balance Holistic Healing, LLC. My signature on this page is required by HIPPA (Health Insurance Portability and Accountability Act).
Please initial in acknowledgement of the patient Bill of Rights and Notice of Privacy Practices.
Functional Dry Needling Consent
Functional Dry Needling® (FDN) involves inserting a tiny monofilament needle in a muscle or muscles in order to release shortened bands of muscles and decrease trigger point activity. This can help resolve pain and muscle tension, and will promote healing. This is not traditional Chinese Acupuncture, but is instead a medical treatment that relies on a medical diagnosis to be effective. Your physical therapist trained by KinetaCore® has met requirements for Level 3 (81 hours of direct coursework) competency in Functional Dry Needling® and is considered a certified Advanced Functional Dry Needling® Practitioner. All training was in accordance with requirements dictated by this facility and by the U.S. state of this practitioner’s licensure. FDN is a valuable and effective treatment for musculoskeletal pain. Like any treatment, there are possible complications. While complications are rare in occurrence, they are real and must be considered prior to giving consent for treatment. Risks: The most serious risk with FDN is accidental puncture of a lung (pneumothorax). If this were to occur, it may likely require a chest x-ray and no further treatment. The symptoms of shortness of breath may last for several days to weeks. A more severe puncture can require hospitalization and re-inflation of the lung. This is a rare complication, and in skilled hands it should not be a major concern. Other risks include injury to a blood vessel causing a bruise, infection, and/or nerve injury. Bruising is a common occurrence and should not be a concern. Patient’s Consent: I understand that no guarantee or assurance has been made as to the results of this procedure and that it may not cure my condition. My therapist has also discussed with me the probability of success of this procedure, as well as the probability of serious side effects. Multiple treatment sessions may be required/needed, thus this consent will cover this treatment as well as consecutive treatments by this facility. I have read and fully understand this consent form and understand that I should not sign this form until all items, including my questions, have been explained or answered to my satisfaction. With my signature, I hereby consent to the performance of this procedure. I also consent to any measures necessary to correct complications which may result. You agree that Dr. Krystal Couture, PT, DPT may perform Functional Dry Needling within the scope of her practice.
Dry Needling Questions
Please elaborate on any "yes" answers.
Please initial in agreement with the Functional Dry Needling Consent Form. Your initials indicate that you thoroughly understand this form.
Typing your full name below serves as your electronic signature and affirms that you have provided accurate information; understand and agree all Pure Balance Holistic Healing, LLC policies; and consent to treatment provided by providers at Pure Balance Holistic Healing, LLC.